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Syphilis: Case Series Our Dermatology Online Case Report SSyphilis:yphilis: ccasease sserieseries Aryambika Krishnan, Aneesh Samayam, Anjan Kumar Patra Department of Dermatology, M.V.J Medical College and Research Hospital, Bangalore, India Corresponding author: Dr. Aryambika Krishnan, E-mail: [email protected] ABSTRACT Syphilis is a sexually transmitted infectious disease caused by Treponema pallidum. This case series reports 3 cases of syphilis and highlights the varied presentation of primary and secondary syphilis which is rare in present day clinical scenario and also the association of syphilis and HIV co-infection. Case 1: A case of primary syphilis presented with solitary painless genital ulcer, associated with lymphadenopathy and VDRL was reactive in 1:32 dilution. Case 2: A retro positive patient presented with primary and secondary syphilitic lesions manifesting as multiple genital ulcers, disseminated skin rashes and oral lesions. VDRL and HIV was reactive. Case 3: A case of secondary syphilis presented with hyperpigmented annular plaques over both palms and soles with healing genital ulcers. VDRL and HIV was reactive. Key words: Syphilis; HIV; Treponema pallidum INTRODUCTION (Fig. 1). “Dory flap sign” was present.Diagnosis was confirmed by VDRL (1:32). Patient was treated Syphilis is an infectious disease caused by Treponema successfully with inj. Benzathine penicillin 2.4 million pallidum. Transmission occurs through sexual units and Tab. Azithromycin 1gm.Counseling was done. contact, vertical transmission, or less frequently, blood transfusions or reused sharp objects. It is common Case 2 among patients with HIV infection and the converse is also true. Syphilis is a disease with devastating effects if 28 year old male patient presented with multiple untreated. Although effective and low-cost treatment painful genital ulcers of 3 weeks duration. He gives is available, syphilis continues to be a public health history of genital ulcers in wife 5months back which healed on treatment. He gives history of sexual contact problem due to lack of awareness [1]. with multiple partners. CASE REPORTS On examination multiple well defined erosions over the glans with clean erythematous floor was Case 1 seen. Single well defined erosion with erythematous floor which was indurated and non tender over the 18 year old male presented with single painless ulcer frenulum (Fig. 2a). Multiple linear fissures with whitish over penis since 2weeks. He gave history of sexual maceration present over the prepuce (Fig. 2b). Inguinal contact with multiple partners since 3 months. There lymphnodes were bilaterally enlarged and non tender. were no other associated signs and symptoms. Blood VDRL was reactive in 1:32 dilutions. HIV was also reactive. A diagnosis of secondary syphilis with On examination multiple, firm, rubbery, non tender candidal balanoposthitis with HIV. Patient was treated lymphnodes were enlarged bilaterally. Single, well with inj. Benzathine penicillin 2.4 million units andTab. defined, indurated, non tender superficial ulcer with Azithromycin1gm.Systemic and topical antifungals was clean floor of 2x3 cm present over prepuce. Single, also given. Counseling was done. Patient was referred indurated, nontender ulcer 2x4cm over coronal sulcus to ART center for further management. How to cite this article: Krishnan A, Samayam A, Patra AK. Syphilis: case series. Our Dermatol Online. 2019;10(3):286-288. Submission: 10.09.2018; Acceptance: 14.11.2018 DOI:10.7241/ourd.20193.17 © Our Dermatol Online 3.2019 286 www.odermatol.com Multiple erosions of 0.5x1 present over shaft of penis. Multiple, smooth, pearly white umbilicated papules over penis and perianal area. Diagnosis was confirmed by VDRL (1:32) and HIV was also reactive. A diagnosis of secondary syphilis with molluscum contagiosum with HIV was made. He was treated with Inj. Benzathine penicillin 2.4million units given IM weekly once for 3weeks. Tab. Azithromycin 1g given. Needling was done for Molluscum Contagiosum. Patient was referred to ART center for further management. DISCUSSION Figure1: Classical Hunterian chancre. Syphilis is a chronic systemic infectious disease caused by T. pallidum. It may affect any organ in the body during its course and may result in life threatening consequences that occur in the cardiovascular and nervous systems. It is distinguished by florid manifestations on one hand and years of asymptomatic latency on the other hand. Transmissible to offspring, and treatable to the point of presumptive cure [2]. Syphilis has many uncommon presentations and requires high level of suspicion. The presentation differs in different stages such as primary, secondary, early latent and late latent. a b Figure 2a and 2b: A retropositive case with syphilis showing multiple Syphilis and HIV infection are common among patients erosions over glans. with HIV infection and the converse is also true. Syphilis produces genital lesions or inflammatory response (macrophages and T cells) that enhance HIV replication. Strong epidemiologic association is observed between HIV and Syphilis. Several unusual manifestations of syphilis observed in the presence of concurrent HIV infection are increased severity of clinical manifestations, rapid progression of syphilis to the tertiary stage a b within a few weeks or months of initial infection, Figure 3a and 3b: Palmoplantar lesions in a retropositive patient with Sero-nonreactivity of Serological test for syphilis in secondary syphilis. the presence of an active secondary stage can occur when associated with HIV thus making the dark field Case 3 examination or skin biopsy essential for the diagnosis of syphilis and relapse in spite of adequate treatment 25 year old male patient presented with annular hence aggressive therapy appears mandatory at the initial dark raised lesions over both palms and soles since presentation of syphilis with HIV infection [3]. Syphilis 20 days. Not associated with itching or pain. History should also be suspected in high risk patients presenting of sexual contact with multiple partners of same a variety of atypical syndromes such as neurologic sex since 2 years. Last contact was 6 months back. symptoms, uveitis or cholestatic hepatitis, especially if History of significant weight loss in last 6months.On palmoplantar lesions are present [4]. examination bilateral inguinal, cervical, epitrochlear lymphnodes were enlarged and nontender. Multiple, CONCLUSION well defined, polysized, annular hyperpigmented plaques with minimal scaling over both palms and soles Syphilis is rarely seen in our present day clinical (Figs. 3a and 3b). “Buschke Ollendorff sign” was present. scenario. This case series is being reported to highlight © Our Dermatol Online 3.2019 287 www.odermatol.com the classical and varied presentation of syphilis and its 2. CDC. Sexually transmitted diseases treatment guidelines, 2010. MMWR. 2010;59(RR-12). possible association with HIV. 3. Shilaih M. Factors associated with syphilis incidence in the HIV- Infected in the era of highly active antiretrovirals.” Ed. Perbinder Consent Grewal. Medicine 96.2 (2017): e5849. PMC. Web. 15 Oct. 2018. 4. Senecal XM, Barkati S, Bouffard D, Martel-Laferrière V. A Secondary syphilis rash with scaly target lesions. Oxf Med Case The examination of the patient was conducted Reports. 2018;2018:omx089. according to the Declaration of Helsinki principles. REFERENCES Copyright by Aryambika Krishnan, et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any 1. Strieder ER, Leon JE, Carvalho YR, Kaminagakura E. Oral syphilis: medium, provided the original author and source are credited. report of three cases and characterization of the infl ammatory cells. Source of Support: Nil, Confl ict of Interest: None declared. Ann Diag Pathol. 2015;19:76-80. © Our Dermatol Online 3.2019 288.
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